AR2728
Expert
I need some help on the following op report and the appropriate ICD/CPT codes. I have what I believe they are but need someone with experience to help me out-Please! It is greatly appreciated!
PREOPERATIVE DIAGNOSIS:
1. Right ankle Grade II open talonavicular dislocation
2. Right ankle trimalleolar fracture
3. Right ankle cuboid fracture dislocation
4. Right foot lateral cuneiform fracture
5. Right talar dome chip fracture
POSTOPERATIVE DIAGNOSIS:
Same
PROCEDURE PERFORMED:
1. Closed reduction and pinning of the talonavicular joint with closed reduction of the calcaneal
cuboid joint
2. I&D of right foot
A tourniquet was placed proximally to the right lower extremity. The right
lower extremity was prepped and draped in a sterile manner. At this point in time under sedation the patient's fracture dislocations of the talonavicular and calcaneal cuboid joint were close reduced. This was very unstable and when the foot would move the mid foot would dislocate. It was determined at this point in time to place 1.62 K-wire through the talonavicular joint. By doing this the dislocation was then held and was not dislocating. Once this was done the patient had a laceration over the medial aspect of the foot. The skin was incised with #15 blade widening the laceration and 9 liters of Crystalloid was used for irrigation or pulsatile lavage. Once this was done final x-rays were taken which showed reduction was maintained. #0 Proline suture was used to close the incision. This was closed loosely. Sterile soft dressing with Xeroform, 4X4's, web roll and a short leg posterior splint was placed. The patient went to recovery in stable condition.
Ok, so here's what I have for ICD 825.32 824.6 825.23 825.24 825.21
CPT 28456 28455-59 97597
PREOPERATIVE DIAGNOSIS:
1. Right ankle Grade II open talonavicular dislocation
2. Right ankle trimalleolar fracture
3. Right ankle cuboid fracture dislocation
4. Right foot lateral cuneiform fracture
5. Right talar dome chip fracture
POSTOPERATIVE DIAGNOSIS:
Same
PROCEDURE PERFORMED:
1. Closed reduction and pinning of the talonavicular joint with closed reduction of the calcaneal
cuboid joint
2. I&D of right foot
A tourniquet was placed proximally to the right lower extremity. The right
lower extremity was prepped and draped in a sterile manner. At this point in time under sedation the patient's fracture dislocations of the talonavicular and calcaneal cuboid joint were close reduced. This was very unstable and when the foot would move the mid foot would dislocate. It was determined at this point in time to place 1.62 K-wire through the talonavicular joint. By doing this the dislocation was then held and was not dislocating. Once this was done the patient had a laceration over the medial aspect of the foot. The skin was incised with #15 blade widening the laceration and 9 liters of Crystalloid was used for irrigation or pulsatile lavage. Once this was done final x-rays were taken which showed reduction was maintained. #0 Proline suture was used to close the incision. This was closed loosely. Sterile soft dressing with Xeroform, 4X4's, web roll and a short leg posterior splint was placed. The patient went to recovery in stable condition.
Ok, so here's what I have for ICD 825.32 824.6 825.23 825.24 825.21
CPT 28456 28455-59 97597